David F. Musto, M.D.,
Professor Of History Of Medicine
Yale University

For more than a century, Americans have praised stimulants, and alternately, Americans have condemned them as the most fearful of all dangerous drugs. Stimulants get their initial popularity because they offer a shortcut to goals admired as typically American: The ability to work without tiring, alertness to solve problems or cheerfulness regardless of the situation. Stay up later to follow the international markets. Drive farther without sleepiness. Faster, more and longer are promised by stimulants. Energy and efficiency are available simply by taking a substance, a substance that can be cheap as well as energizing.

Dr. David Musto of Yale University describes the historical context of stimulant abuse in America.

Alexis de Tocqueville noted this American trait in the 1830s, decades before cocaine arrived as the first powerful stimulant. "It is odd to watch," he wrote, "with what feverish ardor the Americans pursue prosperity, and how they are ever tormented by the shadowy suspicion that they may not have chosen the shortest route to get it." For some Americans the "shortest route" has meant using stimulants, and this helps explain why. At the beginning of a stimulant epidemic, the drugs are favored by so many of those who are goal-oriented, trying to do their job better or working toward some achievement. When a new product promises to give them an edge, they are tempted to improve their chances with the help of chemical engineering.

With our immediate concern over methamphetamine and cocaine, we might think the current epidemic is America's first wave of stimulants. It is actually the second. During the first epidemic, cocaine was widely usedwas legal at the beginningand yet the epidemic did come to a close. Its closure was so complete, when Americans witnessed the rise of cocaine in the 1970s, they thought it was a new phenomenon, and, as it flourished, they despaired of it ever ending. What can we learn from that first epidemic?

The first widespread use of powerful stimulants began in the 1880s with the introduction of pure cocaine to the American market. Cocaine was not discovered in that decade. Its isolation from coca leaves took place 20 years earlier, but it was in the 1880s when substantial production of cocaine got underway.

Preparing the way for pure cocaine was a variety of coca leaf extracts that contained varying amounts of cocaine and were taken by mouth. At the time, most were Vin Mariani, a combination of French red wine and coca leaf extract. Mariani's wine was popular as a tonic and stimulant in Europe and America. Angelo Mariani offered a discount to the clergyPope Leo XIII gave Mariani a gold medaland he offered a further discount to orphanages. Famous people on both sides of the Atlantic allowed their names and faces to be used for Mariani's publicity, including Jules Verne, Charles Gounod, the sculptor of the Statue of Liberty, Frederic Bartholdi, cardinals, cabinet officers, explorers and even Thomas Edison. In one of Mariani's publicity books, even coca wine was touted as an antidote for melancholy and also as an invigorating stimulant for the healthy.

In what is now the New England Journal of Medicine, Dr. Archie Stockwell wrote in 1877 that:

And, after all, unequivocal aphrodisia is what people are looking for.

An American competitor to Vin Mariani, Metcalf's Coca Wine, advertised in the 1880s that it was a valuable tonic for "public speakers, singers and actors." Furthermore, "Athletes . . . and baseball players have found by practical experience that a steady course of coca taken both before and after any trial of strength or endurance will impart energy to every movement." This use of coca as a tonic was so popular that J.S. Pemberton of Atlanta, Georgia, concocted what he called a French Wine Coca in 1885; then, in 1886, he brought forth another coca drink but took out the controversial drug, alcohol, and called his creation "Coca-Cola." In its early years before the cocaine was eliminated, Coca-Cola was described as the "ideal brain tonic"(1893), and there was an ad for that. Thus "the pause that refreshes"(1929) has an interesting ancestry that testifies to the high regard in which coca drinks were held by the public.

If Coca-Cola and Vin Mariani had been the full extent of the public's exposure to coca, we might never have had the intense furor over cocaine that erupted in the decades after 1890 or that recurred during our present drug epidemic. Credit must be given to the advances of organic chemistry that first produced cocaine and also to the pharmaceutical industry that was able to manufacture and distribute cocaine in large amounts. As in the 1970s, cocaine a century earlier was at first expensive and restricted to those who could afford it, later becoming much cheaper and widely used.

Also paralleling our current wave of cocaine use was the initial description of cocaine as harmless and nonaddicting. You will recall the enthusiasm with which Sigmund Freud first wrote about and promoted cocaine. Even wise man Sherlock Holmes used cocaine in the first years after its introduction, although later he would abandon the practice. Within a year of its American introduction, Parke, Davis & Company had cocaine available for the public in 15 different forms. If one had regular crystal cocaine and it was not working, one had a very fine powder cocaine that cost a little bit more. There were also cocaine salve, cocaine cordial, coca wine, coca cigarettes and cocaine for inhaling. Describing its remarkable new technology in 1885, the firm claimed cocaine to be:

A drug which, through its stimulant properties, could take the place of food, make the coward brave, the silent eloquent, free the victims of alcohol and opium habits from their bondage, and, as an anesthetic, render the sufferer insensitive to pain . . .

A couple of years later, the United States Hay Fever Association announced it had chosen cocaine to be its official remedy. Although some physicians had issued serious warnings about cocaine's dangers, the power of its attraction submerged criticism as its use spread to everything from soda pop to headache remedies. After all, how bad can something be that makes you feel good?

In the early stages of a stimulant epidemic, even experts can be misled. Dr. William A. Hammond of New York and Washington, was one of the nation's leading neurologists, a novelist and a playwright. Dr. Hammond wrote extensively about the brain, was a professor at medical schools and would be someone you might well consult if you wanted an expert opinion on cocaine: He liked it, he recommended it and he took it. He even made his own wine/cocaine mixture that he boasted was stronger and more reliable than Vin Mariani. He rejected fearful stories about cocaine. Dr. Hammond "did not believe there was a single instance of a well-pronounced cocaine habit, the patient being able to stop at any time, if he chose to do so." Even when presented with detailed accounts of cocaine's disastrous effects, he did not waver in his belief that cocaine addiction was no more than the equivalent of the coffee or tea habits. Dr. Hammond's example illustrates that experts can be caught up in uncritical enthusiasm for a drug, especially if they like the effects of the drug on themselves.

But this benign view of cocaine could not last. Within 15 years, the positive image of cocaine evolved into the very opposite image, as threatening as the earlier was hopeful. Here is another parallel with our current cocaine problem that can be seen if you compare cocaine's portrayal in the 1970s as a safe, benign stimulant with its aura of extreme danger in the mid-80s.

There are, however, differences between the first and second stimulant epidemics. First, cocaine entered the marketplace in 1884 with no restrictions on it. It was a fully available substance. The laws and regulations did not come until the public demanded them. Second, in the 19th century the right to control the health professions was reserved to the individual states. Our federal system meant our national government did not have the power common to central governments of other nations to oversee physicians and pharmacists and their use of dangerous drugs. Only as a drug came to be seen as a menace were restrictions enacted, and these restrictions were initially at the state or local level. As a result, we had whatever advantages there are in a free economy in drugs much of the last century. Eventually, the fear of drug use grew so great that the traditional separation of federal from state powers was interpreted to allow, for the first time, federal control of prescribing practices over cocaine and the opiates.

As a first step toward controlling cocaine, its distribution was put in the hands of the health professions. For example, the Atlanta City Council in 1901 made it illegal to provide cocaine in any amount or in any form without a doctor's prescription. In 1906, Al Smith introduced a bill in the New York State Assembly to limit cocaine availability to a doctor's prescription.

When state laws did not prove fully effective, Congress surrounded the health professions with rules and regulations that made the use of an opiate or cocaine a serious matter requiring a tax stamp and careful record keeping. This federal legislation, known as the Harrison Act, was passed in 1914.

There was a reason behind the laws' increasing restraints. Cocaine, which started out as an all-American drug, useful for everyone who wanted to gain a step in the race of life, from athletes to clergy to orphans, had become the very image of evil and failure by 1900. A chief reason is the appearance and behavior of those who had become hooked on cocaine. In contrast to the opiate userdulled and noddingthe heavy cocaine user was often paranoid, violent and irresponsible. Fear of cocaine intensified. In 1910, President Taft sent a message to Congress in which cocaine was described as "more appalling in its effects than any other habit-forming drug used in the United States" and as "the most threatening of the drug habits that has ever appeared in this country."

The important difference between addiction to a stimulant and an opiate, say, morphine, can be seen in the heroic life of the "Father of American Surgery," Dr. William Stewart-Halstead. Dr. Halstead was among those unfortunate investigators who began working with the early batches of cocaine in the 1880s. These investigators were unfortunate because they did not know about the mental derangement cocaine could cause. Halstead, who had repeatedly injected himself to learn about cocaine's ability to block pain, became addicted to cocaine. His mind was confused, and he felt a constant craving for more and more cocaine. He was one of the most prominent surgeons in the United States. When he was sought to be the first surgeon-in-chief at the new Johns Hopkins Hospital, his friends helped him get off cocaine through close observation, sea voyages, and even admission to a mental hospital. Finally apparently cured, he did become the head of surgery at Johns Hopkins.

Only after his secret diary was opened in the 1960s did we discover that, after cocaine, Halstead had become addicted to morphine, and remained so for the remainder of his life. Halstead had a difficult time with morphine, but he was able to achieve a great deal. He could never have done so if he had remained on a stimulant. It is important to keep the distinction in mind between stimulants and opioids. I mention this because a couple of years ago I was debating the mayor of Baltimore on this subject, and some people thought Dr. Halstead had been on cocaine all of his life, and there was really no problem. It is very important to keep the distinctions between stimulants and opiates in mind if you are interested in public policy. Maintenance is possible, although difficult, with morphine. But giving more stimulant to a person with a stimulant problem only makes them more anxious and hyperactive. This is a reason why stimulants are more feared than opiates and why stimulant users seek some other substances, like heroin, to take the edge off of their nervousness.

The mental distortion caused by stimulants probably accounts for another difference from opioids. Waves of opioid use tend to be longer and to decline less far compared to stimulant epidemics that tend to be briefer and fall farther. The last cocaine epidemic almost disappeared while opiate users never declined to such an extent. But when I say "quickly," I am speaking as a historian, for an epidemic can seem to go on for quite a while when you are living through it. The first cocaine epidemic lasted from about 1890 to about 1930, or forty years. Our current epidemic began in the 1970s, so if history is a guide, we still have a way to go as changing attitudes reduce cocaine's use. With regard to public attitudes, there was a broad consensus against drugs in the decline phase of the previous epidemic, broader, I believe, than is evident today. This is important because the rise and fall of a drug epidemic are not independent phenomena like the return of a comet. Citizens' attitudes toward drug use are crucial in determining consumption or rejection. An uninformed public eagerly searching for shortcuts favors a rise in drug use. A public that has seen the unfortunate consequences of drug use is more protected against the extravagant claims for a new drug.

One of the consequences of cocaine and other stimulants is they damage the ability to think rationally. There is an additional complication with cocaine; it is the tendency, at least in America, to enmesh the cocaine problem with other social fears of the time. Around 1900, the fear of cocaine became linked with African-Americans living chiefly in the South. Blacks were accused of heavy cocaine use that led to violence, as in a full page from the New York Times in 1914 in which a drug expert is telling about the great problems among blacks in the South. There is very good evidence that blacks used much less cocaine than whites in the South at this time. The importance of the drug issue often gets mixed up with social issues, and it can be a real disservice to our society. Since this era marked the peak of lynchings and removal of voting rights from blacks, we can see how these accusations could serve other purposes. At one point, even the United States Opium Commissioner was encouraging newspapers in the South to repeat these accusations as a way to obtain Southern support for a national anti-cocaine law.

This Velcro-like attachment of drugs to other social fears arises from the enormous symbolic power drugs come to possess in our society. Too often drugs are given as the entire explanation for social problems, obscuring other and deeper causes. Drugs can be given as a reason for not helping inner cities because so many falsely believe the inner cities are predominately populated by drug users. The history of drugs in America illustrates these repeated misperceptions. Knowing that history may help us curb these flights of fear and accusation.

As cocaine declined in the 1930s, a new stimulant appeared: Amphetamine. This had been synthesized long before but was introduced to the United States only in 1932 as Benzadrine. By the end of the 1930s, Benzadrine was promoted as a treatment for hay fever, melancholy and as a general pepper-upper. Amphetamines got off to a slow start in the 1930s and did not become fairly common until World War II, when they were prescribed for fighter pilots and others who had to stay awake and alert.

Again, you will note the use of stimulants in the role of a technology for the mind. After World War II, investigations of amphetamines implicated them in trucking accidents resulting from their use by long-haul drivers. Amphetamines also played a role in an infamous kidnaping and murder case in the Midwest in 1953. The explosion in use, however, occurred in the 1960s when amphetamine and methamphetamine, or "speed," became popular among some youth, most notoriously in the Haight-Ashbury District of San Francisco. Methamphetamine has remained popular on the West Coast and recently has spread to the Midwest.

When we look over the history of stimulants in America, we see our past wave of use faded under broad popular condemnation, and we can hope the current one will do so, also. The saddest impact of a stimulant epidemic is the damage done to users who sought some chemical help with life's problems and soon found themselves in a morass of anxiety, hyperstimulation and paranoia. Yet we have to keep in mind there is a substantial learning process that must take place before we reject trying a drug that promises us joy and accomplishment.

By the time drug use had ceased being a major problem, by 1940, the anger and fear had become so overwhelming that the story of past use of drugs was simply repressed in our society. We developed policies that increased punishments rather than treatment, preferred silence to education, and, if descriptions of drugs were necessary, described them in extreme terms that bore little relation to reality. This strategy was not a problem when drugs were declining in use and their effects were fresh in memory, but the long-term impact was to leave our nation essentially ignorant of drugs. By the time the 1960s arrived, we had re-created conditions of the 19th century, and a more than 50-year struggle with drugs and the practical wisdom painfully gained over those years had been erased from our public memory.

Drugs take their effect when they interact with the brain's physiology, but our response to the problems caused by drugs, the response that may increase or decrease the use of drugs, is a social reaction. When we react, knowledge of the long and dramatic history of drugs in American helps us avoid errors of the past and gives us counsel in making decisions for the future. Thank you very much.

One of our churches includes families who work in the meat packing plants. The clergy report many people are using methamphetamine due to the demands of work, a demand to produce more, faster. Do you see historical parallels of drug abuse with today's increase on the demands for workers to produce more and more?

Physicians and treatment specialists understand people get involved with drugs, not because they are bad or mean people, but due to various pressures. Users think the drug will actually give them something; they will be more with the drug than they could be by themselves. Minors were given cocaine, for example, to work harder, and there is a labor law from the early part of the century about not taking the drugs from the supervisor. It is quite true that, in the late 1930s, there were cases where the management provided drugs to people to work longer and harder because supervisors saw drugs as an instrument to improve work production.

The fact that people are using methamphetamine today for the same reason illustrates one point I always try to make: People do not change over time. Physiology is always the same, and we usually act the same way. If we decide not to take drugs, we have decided from some learning experience not to take them. At the societal level, it is the absence of that learning experience that causes what we call drug epidemics. We must work hard not to forget the past.